基底节区高血压脑出血的外科治疗方式及预后的对比研究
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摘要
高血压脑出血(hypertension intracerebral hemorrhage, HICH)已成为全世界重要的发病与死亡原因,。本论文通过我院收治的123例高血压基底节区出血患者并通过文献复习,对其治疗方法及结果进行回顾性分析,以评价不同的治疗方式对患者术后状态以及总体转归的影响。本次研究严格按照所设计的病例入选及排除标准,对入选的123例临床病例进行研究。按病例所接受的治疗方法,将其分为保守治疗组,标准开颅手术组和微创钻孔引流术组,其中保守组15例,开颅组40例,钻孔组68例。首先对各组病例治疗前状况(包括一般特征、意识状态、出血部位、出血量、手术时机以及临床神经功能缺失程度等)进行评价,来了解术前三组的基本情况是否具有可比性。随后对其术后首次血肿清除率,住院期间的神经功能恢复情况、再出血发生率以及住院时间进行比较。最后进行总体转归的比较,即发病6月后的死亡与残疾发生率(GOS评分)。本论文得出以下结论：(1)对于达到手术指征的基底节区高血压脑出血患者,手术治疗有利于患者的神经功能缺损,特别是语言与肢体肌力的恢复,对其总体转归具有明显的积极影响,并可缩短患者住院治疗时间,因此行外科手术清除血肿是必要的。(2)标准开颅血肿清除术与微创钻孔引流术对于基底节出血患者局灶性神经功能缺失的疗效,并未见明确差异,但对于总体转归来说,微创手术更利于患者的预后。(3)通常对于血肿量相对不大,病情进展相对缓和的患者可选择单纯保守药物治疗,或CT定位下微创钻孔引流术并给予药物治疗,但微创手术治疗对于患者神经功能恢复(特别是语言与肢体肌力)优于单纯保守治疗,并能缩短治疗时间。(4)开颅组的首次血肿清除率高于钻孔组,适合于出血量大,或已出现高颅压危象的患者,并便于必要时可同时行颅骨切除术,对危重患者具有抢救意义。(5)标准开颅血肿清除术与CT定位下微创钻孔引流术相比,其再出血发生率并未明确差异,但不能排除偏倚的影响,建议行进一步研究。
Object:this paper selects 123 patients with hypertensive cerebral hemorrhage of the basal ganglia in the China-Japan union hospital of Jilin University from January 2008 to October 2010, who have surgical indications and completing data.Their methods and results of treatment were retrospectively analyzed, in order to evaluate different treatments to patients who underwent the postoperative status and the influence of the overall outcome.
Methods:In this study, strictly according to the selected and exclusion designing standard, we selected 123 patients for clinical cases were studied. According to the cases accepted by the treatment, which are divided into conservative treatment group, standard craniotomy group and minimally invasive skull drilling operation group. First of all, we evaluate the status of every clinical groups before treatment (including general characteristics, consciousness, the bleeding sites, the bleeding, the operation time and clinical neurologic deficits degree, etc), to understand that the preoperative basic situation of three groups whether comparable. Then,we compare the data of clinical cases on the postoperative hematoma clearance in the first time, postoperative nerve function recovery, the rehemorrhage incidence and the length of time during being in hospital. At last,we make the comparison of the overall outcome, namely the death and disability incidence (GOS) of the disease.
Results:(1) The general characteristics,preoperatie state of consciousness, the bleeding sites, the bleeding, the operation time and clinical neurological deficits, including language and body degree of clinical function lack of muscle strength, such as degree obtained by statistics test, the difference in groups were no statistically significant (P> 0.05). (2)The differences in three groups of the clinical neurological deficits degree was not statistically significant (P> 0.05).Compared with the preoperative, the conservative group has no statistically significant differences (P> 0.05)between before and after treatment, but postoperative the differences of the operation groups which are between preoperative and postoperative are statistically significant (P< 0.01). Focusing on comparison language and body strength, there is no statistically significant difference(P> 0.05),however,the conservative treatment group is statistically significantly different(P<0.05)to the operation groups. (3) The first postoperative hematoma clearance is according to the first preoperative Head CT results calculation,the craniotomy group is74.51±10.32%, and the drilling group is 35.12±8.60%.The between-group differences is statistical significance (P< 0.05). (4) After treatment, the conservative group, craniotomy group and drilling group's rehemorrhage incidences are separately 26.67%,10.00%,andl3.24%,there is no statistically significant difference (P> 0.0167, Bonferroni correction) in three groups.. (5) The conservative and operation treatment groups in the average length of hospitalization time have a statistically significant difference (P< 0.05), but the difference is not statistically significant (P> 0.05)between operation groups. (6) In six months, the poor-prognosis incidence (GOS<3)of the conservative group, craniotomy group and drilling group are 100.00%,64.10%,35.33% respectively, and mortality is 12.50%.20.51%, is 42.86%.Three groups' differences of nonconformities prognosis are statistically significant (P< 0.0167), and mortality of conservative treatment group is statistically significantly diferent(P< 0.0167)from the operation groups, and the difference between the two operation groups was not statistically significant (P> 0.0167).
Conclusions:(1) The surgical operation treatment takes advantage to nerve function recovered of patiens, and lowers mortality of them, so to take surgical operation is necessary. (2)For recovery of clinical neurologic deficits, the surgical treatment to the basal ganglia cerebral hemorrhage patients has a positive impact. (3) the first hematoma clearance of craniotomy group was higher than the drilling group.so standard craniotomy is suitable for patients who have massive bleeding or appeared high cranial pressure crisis,and to facilitate necessary patients can be simultaneously do resection of the skull. (4) The standard craniotomy can not specifically reduce rehemorrhage rate after hematoma remove, so we advice to do further research. (5) The curative effect of the standard craniotomy and minimally invasive skull drilling operation which is used to treat basal ganglia hemorrhage patients with focal neurologic deficits does not be seen a statistically significant difference, but for the overall outcome, minimally invasive operation is more conducive to the prognosis of patients.
Object:this paper selects 123 patients with hypertensive cerebral hemorrhage of the basal ganglia in the China-Japan union hospital of Jilin University from January 2008 to October 2010, who have surgical indications and completing data.Their methods and results of treatment were retrospectively analyzed, in order to evaluate different treatments to patients who underwent the postoperative status and the influence of the overall outcome.
Methods:In this study, strictly according to the selected and exclusion designing standard, we selected 123 patients for clinical cases were studied. According to the cases accepted by the treatment, which are divided into conservative treatment group, standard craniotomy group and minimally invasive skull drilling operation group. First of all, we evaluate the status of every clinical groups before treatment (including general characteristics, consciousness, the bleeding sites, the bleeding, the operation time and clinical neurologic deficits degree, etc), to understand that the preoperative basic situation of three groups whether comparable. Then,we compare the data of clinical cases on the postoperative hematoma clearance in the first time, postoperative nerve function recovery, the rehemorrhage incidence and the length of time during being in hospital. At last,we make the comparison of the overall outcome, namely the death and disability incidence (GOS) of the disease.
Results:(1) The general characteristics,preoperatie state of consciousness, the bleeding sites, the bleeding, the operation time and clinical neurological deficits, including language and body degree of clinical function lack of muscle strength, such as degree obtained by statistics test, the difference in groups were no statistically significant (P> 0.05). (2)The differences in three groups of the clinical neurological deficits degree was not statistically significant (P> 0.05).Compared with the preoperative, the conservative group has no statistically significant differences (P> 0.05)between before and after treatment, but postoperative the differences of the operation groups which are between preoperative and postoperative are statistically significant (P< 0.01). Focusing on comparison language and body strength, there is no statistically significant difference(P> 0.05),however,the conservative treatment group is statistically significantly different(P<0.05)to the operation groups. (3) The first postoperative hematoma clearance is according to the first preoperative Head CT results calculation,the craniotomy group is74.51±10.32%, and the drilling group is 35.12±8.60%.The between-group differences is statistical significance (P< 0.05). (4) After treatment, the conservative group, craniotomy group and drilling group's rehemorrhage incidences are separately 26.67%,10.00%,andl3.24%,there is no statistically significant difference (P> 0.0167, Bonferroni correction) in three groups.. (5) The conservative and operation treatment groups in the average length of hospitalization time have a statistically significant difference (P< 0.05), but the difference is not statistically significant (P> 0.05)between operation groups. (6) In six months, the poor-prognosis incidence (GOS<3)of the conservative group, craniotomy group and drilling group are 100.00%,64.10%,35.33% respectively, and mortality is 12.50%.20.51%, is 42.86%.Three groups' differences of nonconformities prognosis are statistically significant (P< 0.0167), and mortality of conservative treatment group is statistically significantly diferent(P< 0.0167)from the operation groups, and the difference between the two operation groups was not statistically significant (P> 0.0167).
Conclusions:(1) The surgical operation treatment takes advantage to nerve function recovered of patiens, and lowers mortality of them, so to take surgical operation is necessary. (2)For recovery of clinical neurologic deficits, the surgical treatment to the basal ganglia cerebral hemorrhage patients has a positive impact. (3) the first hematoma clearance of craniotomy group was higher than the drilling group.so standard craniotomy is suitable for patients who have massive bleeding or appeared high cranial pressure crisis,and to facilitate necessary patients can be simultaneously do resection of the skull. (4) The standard craniotomy can not specifically reduce rehemorrhage rate after hematoma remove, so we advice to do further research. (5) The curative effect of the standard craniotomy and minimally invasive skull drilling operation which is used to treat basal ganglia hemorrhage patients with focal neurologic deficits does not be seen a statistically significant difference, but for the overall outcome, minimally invasive operation is more conducive to the prognosis of patients.
引文
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[1]Lewis B. Morgenstern, J. Claude Hemphill, Guidelines for the Management of Spontaneous Intracerebral Hemorrhage:A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association, Stroke,2010,41:2108-2129.
[2]徐力,吴春辉,邓洁瑜,等.大骨瓣开颅术对重症高血压脑出血的临床分析.海南医学,2005,8：112-114.
[3]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.中华医学杂志,2005,85：3118-3122.
[4]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.中华医学杂志,2005,85：2238-2242.
[5]Rabinstein AA, Atkinson JL, Wijdicks EFM. Emergencycraniotomy in patientsw orsening due to expanded cerebralhematoma:to what purpose? Neurology,2002,58: 1367-1372.
[6]Prasad K, Rrowan G, SirvastavaA, et a.l Surgery in primary supratentorial intracerebralhematoma:A meta-analysis of randomized trails. Acta Neurol Scand,1997,95:103-110.
[7]Broderick J,Connolly S,Feldmann E,etal.Guidelines for the management of spontaneous intracerebral hemorrhage in adults:2007 update:a guideline from the American Heart Association/American Stroke Association Stroke Council,Hig Blood Pressure Research Council,and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke,2007,38(6):2001-2023.
[8]Marquardt G, Wolff R, JanzenRW, et al. Basal ganglia haematomas in non-eomatose patienis:subacute stereotactic aspiration improves long-term outcome in comparison to purely medicaltreatment. Neurosurg Rev.2005:28(1):64-69.
[9]杨友松.国内外脑出血基础研究及治疗现状和今后发展的方向.临床内科杂志.2007,24(6)：365-367.
[10]Brott T, Broderick M, Kothari T, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke,1997,28(1):1-5.
[11]LeeKR, kawalN, Kim S, et al. Mechanisms of edema formation after intracerebral hemorrhage effects of thrombin on cerebral blood flow,blood-brain-barrierermeability and cell survival in a rat model, Neurosurg,1997,86(2):272.
[11]Xi G, Keep R F, Hoff J T. Pathophysiology of brain edema fomation. Neurosurg Clin N Am,2002,13(3):371-383.
[12]Castillo J, Davalos A, Alvarez-Sabin J. Molecular signatures of brain injury after intracerebral bemorrhage. Neurology,2002,58(4):624-629.
[13]GEBEL JM JR, JAUCH EC, BROTT TG, et al. Natural history of pefhematomal edema in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke,2002,33: 2631-2635.
[14]SANSING LH, KAZNATCHEEVA EA, PERKINS CJ,et al. Edema afteebral hemorrhage, correlations with coagulation parameters and treatment. Neurosurg,2003,98:985-992.
[15]Karibe H, Shimizu H, Tominaga T, et a.l Diffusion-weighted magnetic resonance imaging in the early evaluation of corticospinal tract injury to predict functionalmotor outcome in patientswith deep intracerebral hemorrhage. JNeurosurgery,2000,92:8-63.
[16]庞力,周良辅.微创手术治疗高血压脑出血的术式比较.中国微侵袭神经外科杂志,2001,6(3)：147—150.
[17]SiddiqueMS, MendelowAD.Surgical treatment of intracerebral hemorrhage.British Medical Bulletin,2000,56(4):444-456
[18]Sterzi R,Vidale S.Treatment of intracerebral hemorrhage:the clinical evidences[J].NeurolSci,2004,24:12.
[19]Ruth A,Josef S F,Chris W,etal.Intracerebral haemorrhage:surgical therapy vs. patient adapted treatment concept[J].Clin Neurosci,2004,11(3):259-262.
[20]Maira G,Anile C,Colosimo C,Rossi,et al. Surgical treatment of primary supra-tentorial intracerebral hemorrhage in stuporous and comatose patients. Neurol Res, 2002,24:54-60.
[21]Siddique MS,Mendelow AD.Surgical treatment of intracerebral hemorrhage[J]. British Medical Bulletin,2000,56:444-446.
[22]Schaller B, Graf R, Sanada Y, et a.l Hemodynamic andmetabolic effects ofdeco mpressive hemicraniectomy in nor-malbrain. An experimental PET study in cats. BrainRes, 2003,982:31-37.
[23]Ziai WC, Port JD, Cowan JA, eta.l Decompressive crani-ectomy for intractable cerebral edema:experience of a sin-gle center. J Neurosurg Anaesthesia 2003,15:25-32.
[24]徐力,吴春辉,邓洁瑜,等.大骨瓣开颅术对重症高血压脑出血的临床分析.海南医学,2005,8：112-114.
[25]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.中华医学杂志,2005,85：2238-2242.
[26]Cucchiara B, Messe S, Sansing L, Kasner S, Lyden P, CHANT Inves-tigators. Hematoma growth in oral anticoagulant related intracerebral hemorrhage. Stroke.2008,39: 2993-2996.
[27]Prasad K, Rrowan G, SirvastavaA, et a.l Surgery in pri-mary supratentorial intracerebralhematoma:A meta-analysis of randomized trails. Acta Neurol Scand,1997,95: 103-110.
[28]孙秀海,张振兴.CT定向钻孔引流术与传统开颅术治疗高血压脑出血448例对比观察.山东医药,2005,15：45-46.
[29]KirollosRW, TyagiAK, Ross SA, et a.l Management of spontaneous cerebellarhe matomas:a prospective treatment protocol. Neurosurgery,2001,49:1378-1386.2000,1:72-73.
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[1]Lewis B. Morgenstern, J. Claude Hemphill, Guidelines for the Management of Spontaneous Intracerebral Hemorrhage:A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association, Stroke,2010,41:2108-2129.
[2]徐力,吴春辉,邓洁瑜,等.大骨瓣开颅术对重症高血压脑出血的临床分析.海南医学,2005,8：112-114.
[3]王德江,王硕,赵元立,等.高血压脑出血外科治疗近期预后多因素分析.中华医学杂志,2005,85：3118-3122.
[4]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.中华医学杂志,2005,85：2238-2242.
[5]Rabinstein AA, Atkinson JL, Wijdicks EFM. Emergencycraniotomy in patientsw orsening due to expanded cerebralhematoma:to what purpose? Neurology,2002,58: 1367-1372.
[6]Prasad K, Rrowan G, SirvastavaA, et a.l Surgery in primary supratentorial intracerebralhematoma:A meta-analysis of randomized trails. Acta Neurol Scand,1997,95:103-110.
[7]Broderick J,Connolly S,Feldmann E,etal.Guidelines for the management of spontaneous intracerebral hemorrhage in adults:2007 update:a guideline from the American Heart Association/American Stroke Association Stroke Council,Hig Blood Pressure Research Council,and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke,2007,38(6):2001-2023.
[8]Marquardt G, Wolff R, JanzenRW, et al. Basal ganglia haematomas in non-eomatose patienis:subacute stereotactic aspiration improves long-term outcome in comparison to purely medicaltreatment. Neurosurg Rev.2005:28(1):64-69.
[9]杨友松.国内外脑出血基础研究及治疗现状和今后发展的方向.临床内科杂志.2007,24(6)：365-367.
[10]Brott T, Broderick M, Kothari T, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke,1997,28(1):1-5.
[11]LeeKR, kawalN, Kim S, et al. Mechanisms of edema formation after intracerebral hemorrhage effects of thrombin on cerebral blood flow,blood-brain-barrierermeability and cell survival in a rat model, Neurosurg,1997,86(2):272.
[11]Xi G, Keep R F, Hoff J T. Pathophysiology of brain edema fomation. Neurosurg Clin N Am,2002,13(3):371-383.
[12]Castillo J, Davalos A, Alvarez-Sabin J. Molecular signatures of brain injury after intracerebral bemorrhage. Neurology,2002,58(4):624-629.
[13]GEBEL JM JR, JAUCH EC, BROTT TG, et al. Natural history of pefhematomal edema in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke,2002,33: 2631-2635.
[14]SANSING LH, KAZNATCHEEVA EA, PERKINS CJ,et al. Edema afteebral hemorrhage, correlations with coagulation parameters and treatment. Neurosurg,2003,98:985-992.
[15]Karibe H, Shimizu H, Tominaga T, et a.l Diffusion-weighted magnetic resonance imaging in the early evaluation of corticospinal tract injury to predict functionalmotor outcome in patientswith deep intracerebral hemorrhage. JNeurosurgery,2000,92:8-63.
[16]庞力,周良辅.微创手术治疗高血压脑出血的术式比较.中国微侵袭神经外科杂志,2001,6(3)：147—150.
[17]SiddiqueMS, MendelowAD.Surgical treatment of intracerebral hemorrhage.British Medical Bulletin,2000,56(4):444-456
[18]Sterzi R,Vidale S.Treatment of intracerebral hemorrhage:the clinical evidences[J].NeurolSci,2004,24:12.
[19]Ruth A,Josef S F,Chris W,etal.Intracerebral haemorrhage:surgical therapy vs. patient adapted treatment concept[J].Clin Neurosci,2004,11(3):259-262.
[20]Maira G,Anile C,Colosimo C,Rossi,et al. Surgical treatment of primary supra-tentorial intracerebral hemorrhage in stuporous and comatose patients. Neurol Res, 2002,24:54-60.
[21]Siddique MS,Mendelow AD.Surgical treatment of intracerebral hemorrhage[J]. British Medical Bulletin,2000,56:444-446.
[22]Schaller B, Graf R, Sanada Y, et a.l Hemodynamic andmetabolic effects ofdeco mpressive hemicraniectomy in nor-malbrain. An experimental PET study in cats. BrainRes, 2003,982:31-37.
[23]Ziai WC, Port JD, Cowan JA, eta.l Decompressive crani-ectomy for intractable cerebral edema:experience of a sin-gle center. J Neurosurg Anaesthesia 2003,15:25-32.
[24]徐力,吴春辉,邓洁瑜,等.大骨瓣开颅术对重症高血压脑出血的临床分析.海南医学,2005,8：112-114.
[25]赵继宗,周定标,周良辅,等.2464例高血压脑出血外科治疗多中心单盲研究.中华医学杂志,2005,85：2238-2242.
[26]Cucchiara B, Messe S, Sansing L, Kasner S, Lyden P, CHANT Inves-tigators. Hematoma growth in oral anticoagulant related intracerebral hemorrhage. Stroke.2008,39: 2993-2996.
[27]Prasad K, Rrowan G, SirvastavaA, et a.l Surgery in pri-mary supratentorial intracerebralhematoma:A meta-analysis of randomized trails. Acta Neurol Scand,1997,95: 103-110.
[28]孙秀海,张振兴.CT定向钻孔引流术与传统开颅术治疗高血压脑出血448例对比观察.山东医药,2005,15：45-46.
[29]KirollosRW, TyagiAK, Ross SA, et a.l Management of spontaneous cerebellarhe matomas:a prospective treatment protocol. Neurosurgery,2001,49:1378-1386.2000,1:72-73.
[30]Backlund ED, HolstVH. Controled subtotal evacuation of intracerebral hematomas by stereotactic technique. Surg-Neuro.l1978,9:99-101.
[31]Teernstra OP, Evers SM, Lodder J, et a.l Stereotactic treatment of intracerebral hematoma by means of a plas-minogen activator:a multicenter randomized controlled trial (SICHPA). Stroke,2003,34:968-974.
[32]NINDS ICH Workshop Participants, Priorities for clinical research in intracerebralhemorrhage. report from a Nation-al Institute of Neurological Disorders and Stroke Work-shop. Stroke,2005,36:23-41.
[33]Naff NJ, Carhuapoma JR, W illiamsMA, et a.l Treatment of intraventricular hemorrhage with urokinase:effects on 30-day survival Stroke,2000,31:841-847.
[34]杜建新,凌锋,谌燕飞,等.小骨窗开颅术和钻孔引流术治疗脑出血疗效的对比研究.中国脑血管病杂志,2004,1：10-12.
[35]NaffN, HanleyDF, KeyP, et a.l Intraventricularuroki-nase speeds clot resolution: results of a pilot, prospective, randomized, double blind, controlled tria.l Neurosurg,2004,54：577-583.
[36]赵继宗,季按.脑卒中外科治疗的现状与展望.中华神经医学杂志,2002,1(1)：1-3.
[37]刘明.CT导向脑立体定向手术治疗高血压脑出血60例报告.中国临床医学2002,9(6)：414-416.
[38]杜建新,凌锋,堪燕飞,等.小骨窗开颅术和钻孔引流术治疗脑出血疗效的对比研究.中国脑血管病杂志,2004,1(7)：292-294
[39]马连柱,蔡建圃.不同手术方法治疗高血压脑出血128例分析.实用神经疾病杂志,2005,8(1)：76-77.